Pericardial Disease & Cardiac Trauma Flashcards
What are the three most common responses to pericardial injury?
- Acute Pericarditis
- Pericardial Effusions
- Constrictive Pericarditis
A stiff, fibrous membrane that attaches to the sternum, mediastinum, and diaphragm.
-Helps maintain hearts position in the thoracic cavity
Parietal Pericardium
What is the Pericardial Sac?
-Space between layers (Visceral and Parietal Pericardium)
-Pericardial fluid lubricates the heart
Which type of Pericarditis occurs after an MI?
Dressler’s Syndrome (!!)
Delayed. Weeks to months after a myocardial event
-Often auto-immune response to damage to pericardium
What causes Acute Pericarditis?
Mostly caused by viral infection.
-Usually transient and uncomplicated
-Sometimes follows an MI
-1-3 days post transmural MI
What is Acute Benign Pericarditis?
-Acute pericarditis in absence of pericardial effusion
-Does NOT alter cardiac function
-Inflammation for unknown reason.
What are the S/Sx of Pericarditis?
Chest pain, friction rub, EKG changes
-Chest pain is acute and worsens with inspiration
-Low grade fever with sinus tachycardia
-Friction rub
How do you diagnose Pericarditis?
-Symptoms
-EKG changes in 90% of people (diffuse ST segment elevation and PR segment depression and t wave inversions)
-Caused by inflammation of superficial myocardium
What is the treatment for Acute Pericarditis?
1) Aspirin or NSAIDs!!!
-Decrease the inflammation
2) Codeine (for pain relief)
3) Colchicine
-Anti-inflammatory used for Gout
4) Steroids frequently cause relapse once discontinued, so used only if other therapy doesn’t work
What is unique about Relapsing Pericarditis?
-Can be relapsing or chronic in nature
-Relapses are rarely life threatening (usually don’t effect cardiac function)
-Two types: Incessant or Intermittent
What is Incessant Pericarditis?
Pericarditis that relapses when anti-inflammatory drugs are withdrawn (<6weeks).
-Colchicine is associated with less relapse
What is Intermittent Pericarditis?
Relapses after prolonged periods without drug treatments (>6weeks)
What is Resistant Pericarditis?
Treated with standard therapies (ASA, Prednisone)
-may respond to Immunosuppressant therapy- azathioprine (Imuran)
What is Pericarditis after Cardiac Surgery?
-Postcardiotomy syndrome presents as acute pericarditis
-The cause is infective or autoimmune
-Can occur in any patient who had pericardectomy (all CABG, valve, epicardial pacer implantation, and most congenital surgery)
-Incidence of 10-40% of cardiac surgery patients
-Less common with OHT due to immunosuppression
-More common in pediatric patients
-Treat like pericarditis (ASA or NSAIDS)
-Tamponade is possible, but rare (0.1-0.6%)
What is an effusion?
An increase in pericardial volume
How much fluid is usually contained in the Pericardial Space?
25-50 ccs
What are causes of Acute Pericarditis & Pericardial Effusion?
1) Infection: Viral, Bacterial, Fungal, TB
2) Myocardial Infarction (Dressler’s)
3) Trauma or Cardiotomy
4) Metastatic Disease
5) Drugs
6) Mediastinal radiation
7) Systemic Disease - Rheumatoid Arthritis, Lupus, Scleroderma
Define Acute Pericardial Effusion
Quick changes as small as 50ml can lead to increased pressure (tamponade).
Define Chronic Pericardial Effusion
-Gradual increases allow for pericardial stretch
-Up to 2 liters can be accumulated
How does Cardiac Tamponade develop from pericardial effusion?
As pericardial pressure increases, RAP increases in parallel.
-Atrial and ventricular filling is restricted
-SV becomes fixed, so CO becomes rate dependent
-Remember: CO=HR x SV
What are the clinical features of cardiac tamponade?
-Acute increases of only 40-50 ml of fluid will cause a rapid rise in pressure and tamponade
-Large effusions compress adjacent structures (esophagus, trachea, lung) leading to anorexia, dyspnea, cough, hoarseness, dysphagia
-Kussmaul’s Sign
-Pulsus Paradoxus
-CVP almost always increased above RVP – this is what maintains forward flow and preserves CO
-Activation of the SNS into overdrive (especially tachycardia) is an attempt to maintain CO and patient survival. CO is HR dependant
-Contractility is great, preload is lacking
-Primary problem is reduced ventricular preload, not failure of myocardial contractility
-Eventual “equilibration of pressures”
What is Kussmaul’s Sign?
JVD during inspiration
What is Pulsus Paradoxus?
-Decrease in SBP > 10mmHG during inspiration
-Selective impairment of diastolic filling of the LV
-Present in 75% of patients with acute tamponade vs 30% of patients with chronic pericardial effusion.
What do Kussmaul’s Sign and Pulsus Paradoxus reflect?
Both Kussmaul’s sign and Pulsus paradoxus reflect dyssynchrony or opposing responses of the RV and LV to filling during the respiratory cycle. Also called Ventricular Discordance
